Healthcare Provider Details

I. General information

NPI: 1073609327
Provider Name (Legal Business Name): JOHN TIMOTHY WELLS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 E 67TH ST
NEW YORK NY
10021-5901
US

IV. Provider business mailing address

109 E 67TH ST
NEW YORK NY
10021-5901
US

V. Phone/Fax

Practice location:
  • Phone: 212-772-6683
  • Fax: 212-452-3131
Mailing address:
  • Phone: 212-772-6683
  • Fax: 212-452-3131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number185534
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: